MDS Alert

You must provide a plethora of data, just in the first hour of the surveyor’s visit.

State survey agencies (SAs) have been busy contacting long-term care (LTC) providers to prepare them for the MDS-Focused Survey, which will scrutinize your facility’s MDS coding accuracy and staffing. You must prepare now if you want to get through the survey with the best possible outcome.

The Texas Department of Aging and Disability Services (DADS) and the North Carolina Department of Health and Human Services (NCDHHS), and other states are currently relaying information to nursing facilities on what to expect from the surveys. Here’s what state SAs are saying.

Have This Key Data at Your Fingertips

For most states, the survey takes two days on-site. Surveyors will request the following from nursing facilities:

1. Complete Worksheet #1 within one hour of the surveyors’ arrival at your facility (see “Can You Fill Out This MDS-Focused Survey Worksheet In 1 Hour?” on page 53).

Complete this worksheet based on the resident census on the day of the on-site survey, for each resident in the last 90 days. The areas are:

• Restraints;

• Falls with major injuries;

• Pressure ulcers;

• Urinary tract infections (UTIs);

• Urinary catheters;

• Antipsychotic medications;

• Extensive assistance of two or more;

• Skilled; and

• LTC.

You should have at least one entry for each resident, because at the bare minimum each resident is either Skilled (receiving therapy services) or LTC, according to an email from the NCDHHS, shared by MDS expert Judy Wilhide-Brandt, RN, BA, RAC-MT, C-NE of Judy Wilhide Consulting Inc. in a May 10 blog posting on her website. 

2. Also within one hour, provide surveyors with Admissions/Readmissions within the last 90 days from an Acute Care or Psychiatric Hospital, who are currently residents in the facility. Include the resident’s:

• Name;

• Room number;

• Date of discharge (if discharged);

• Date of admission/readmission to the facility;

• Disposition;

• Where resident was admitted from; and

• Whether resident is Skilled or LTC.

Gather Your Staffing Info, Too

3. From the two above items, the survey team will pull a sample of residents to review (North Carolina is selecting 10 sample residents). Surveyors may also do the staffing component at this time, to verify that you’ve posted the required staffing data and that you have staff as scheduled and required.

4. Provide the last 18 months of staffing data for the survey team to review. Surveyors will typically verify whether there is a wound care nurse, identify who is responsible for staffing, and request a list of key personnel.

5. Be prepared to furnish your policies and procedures for staffing and scheduling, RAI, and others as needed.

6. Provide a completed Form CMS 671, LTC Facility Application for Medicare and Medicaid (download here: www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS671.pdf), typically within 24 hours of the surveyors’ arrival or the entrance conference.

Remember: Survey Produces Real Citations

What’s more: Although the on-site surveys will focus on MDS accuracy and staffing, “facilities must be in complete compliance with all regulations,” DADS warned its providers. “If surveyors find a facility in noncompliance with any regulation, the finding will result in deficiencies.” 

DADS told providers that Texas state surveyors will hold an exit conference at the end of the survey and discuss preliminary findings, but not scope and severity. Instead, Texas surveyors will include scope and severity in the statement of deficiencies.

Contact us: We want to hear from you about your experiences with the MDS-Focused Surveys! What information did surveyors request from you? How long did it take for you to compile this information? What, if any, problems or roadblocks are you encountering while participating in the survey? Email MDS Alert Editor Sarah Terry at sarahterrync@yahoo.com to share your thoughts and experiences.